Eating Disorders in the Primary Care Setting

What do we do?

Elaine Brown, PA-C

Objectives - Identify risk factors and personality characteristics that predispose patients to the development of an eating disorder.

- Learn how to take an Eating Disorder history with a focus on identifying current or past behaviors.

- Review common medical complications the primary care provider needs to monitor for and treat.

- Learn how to manage a patient once he/she has been discharged from a higher level of care (residential/partial hospitalization/IOP)

- Identify community resources that can aid in monitoring patients (ie: School nurses, guidance counselors, athletic trainers, ect)

- Discuss the importance of a multi-disciplinary team approach to management of these patients and the role of the PCP on this team.

Anorexia Nervosa DSM-5 Diagnostic Criteria1. Restriction of energy intake relative to requirements leading to a significantly low

body weight in the context of age, sex, developmental trajectory, and physical health

2. Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.

3. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.

Note: There is no longer a specific percentage of weight loss required (<85% expected) and the requirement of amenorrhea was also removed with the DSM 5.

Anorexia NervosaPersonality Characteristics

- Most likely adolescent females but we are seeing increasing numbers of adult and postmenopausal women developing new onset anorexia

- Prevalence is also increasing in men- Typically have a history of being “high strung,” driven, perfectionistic, self

critical- Frequently have a preexisting low self esteem and prone to anxiety

Bulimia NervosaDSM-5 Diagnostic Criteria1. Recurrent episodes of binge eating characterized by BOTH of the following:

a. Eating in a discrete amount of time (within a 2 hour periods) an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances

b. Sense of lack of control over eating during an episode2. Recurrent inappropriate compensatory behavior in order to prevent weight gain

(self-induced vomiting, misuse of laxatives, diuretics or other medications, fasting or excessive exercise.)

3. The binge eating and compensatory behaviors both occur, on average, at least once a week for three months

4. Self-evaluation is unduly influenced by body shape and weight5. The disturbance does not occur exclusively during episodes of anorexia nervosa

Bulimia NervosaWhat is considered purging?

- Self induced vomiting- Laxative abuse, especially stimulant laxatives- Diuretic abuse- Excessive exercise- Thyroid medication abuse- Insulin restriction

Bulimia Nervosa Personality Characteristics

- More likely to have impulse behaviors compared with pts with AN- More likely to use other substances (drugs, alcohol)- Higher suicide risk?

ARFID- Avoidant Restrictive Food Intake Disorder

An eating or feeding disturbance manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:

1. Significant weight loss (or failure to achieve expected weight gain or faltering growth in children)

2. Significant nutritional deficiency3. Dependence on enteral feeding or oral nutritional supplements4. Marked interference with psychosocial functioning

ARFID

How is ARFID different from Anorexia?

- ARFID frequently develops after a traumatic experience while eating (ie: choking, watching someone else choke).

- Concern about aversive consequences of eating such as vomiting (not fear of gaining weight).

- Avoidance may be based on the sensory characteristics of food.- ARFID lacks the body image or weight concerns though may result in the same

physical findings. - No compensatory behaviors (purging, excessive exercise)

OSFED- Other Specified Feeding or Eating DisorderThis category applies to presentations in which symptoms characteristic of a feeding or eating disorder cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders previously listed.

1. Atypical AN: all the criteria for anorexia nervosa are met, except that despite significant weight loss, the individual’s weight is within or above the normal range

2. BN of low frequency and or limited duration: All the criteria for BN are met, except that the binge eating and inappropriate compensatory behaviors occur, on average, less than once a week and/or for less than 3 months

OSFEDOther unofficial diagnosis that may better articulate a patient's specific behaviors or method of weight control:

Orthorexia: “Clean eating” to the extent a patient is malnourished, have an inability to be flexible with eating when no “appropriate” foods are available.

Drunkorexia: Restricting the intake of food and “saving calories” for alcohol consumption

Diabulimia: Insulin dependent diabetics restricting insulin to cause weight loss

Taking the HistoryThink of eating disorders as a unique neurobiological response to starvation.

First, we have to recognize how the brain reacts to starvation in an attempt to protect itself (ie: obsessions about food.)

Secondly, we have to identify who is at risk for the unique response we see in patients with eating disorders (intense fear of gaining weight that reinforces and thus perpetuates the starvation.)

Taking the History The Keys Study- The Minnesota Starvation Experiment

- “Men of hunger: a psychological manual for relief workers.”- Published in 1946, an abbreviated manual designed to help relief and aid workers understand the

psychology of starved Europeans they encountered after WWII as it pertained to refeeding them. Gave instructions of how to set up mess tents, how to serve food (temperature, proportions, conversations to avoid)

- Ancel Keys was the lead researcher.

Taking the History“We approached the experiment skeptically, never thinking that the proposed 25% weight loss could induce a profound set of changes. We had thought that the striking changes which are described in starving peoples occurred only in extreme cases or were largely caused by the tremendous insecurities and disruptions which accompanied war and famine. But we were mistaken- and perhaps our observations will help you decipher those behavioral patterns which are due to physiological starvation itself as compared with those aspects due to the many other distressing forces which act upon these unfortunate peoples.” - Ancel Keys

Taking the History- 36 Civilian Public Service volunteers (conscientious objectors), ages 20-33

- Selection criteria was based on the 4 following personality characteristics:- Physical health- Sound mental health: Minnesota Multiphasic Personality Inventory or MMPI- The ability to get along well with others- Genuine interest in relief and rehabilitation

- 1 year study - 3 months to establish baseline weight and caloric intake- 6 months of starvation to lose 25% body weight- 3 months of rehabilitation- The real purpose of the study

Taking the History- Within the starvation diet vitamins A, D, C, thiamine and niacin were tracked

and given in sufficient quantities such that the research would follow that of starvation, not a specific vitamin deficiency

- Men were required to work 15 hours a week, walk 22 miles a week in addition to walking to the dining hall (1.5 mile round trip, twice a day) and physical abilities testing in the lab.

Taking the HistoryBehavior Changes

- Changes were noted in the following categories :- Motivation- Physical - Emotional- Intellectual- Socail

Motivation “When food is supplied, the individual is often caught between his desire to gulp it down ravenously, and to consume the prized possession slowly, covetously…”1

- Men were noted to cut their food into small pieces and consume the meal over the course of hours rather than minutes.

“Many of the men toyed with their food, making weird and seemingly distasteful concoctions.” 1

- In the eating disordered patient this is a common behavior thought to make food less appealing and therefore easier to avoid or to decrease the pleasure of the food thereby decreasing some of the guilt “at least I didn’t enjoy it.”

PhysicalThe men were noted to have an overall decrease in spontaneous movement, loss of interest in women and other social relationships.

- The fact that eating disorder patients do not seem hindered by their physical decline is something unique to the disorder. Pts with eating disorders remain surprisingly active despite their severe calorie restriction.

Emotional Overall dulling of emotional responses with the exception of irritation. “The frustration seemed to dictate their behavior in other areas.”

Lack of humor, lack of conversation at meal times. Decreased interest in all activities outside of anything having to do with food.

Taking the History

Habits the men developed:

- Chewing gum. Two men were finally cut off after they began to chew 40+ packages of gum a day

- Collecting cookbooks, reading recipes, planning meals, people watching in restaurants

- The men did have unlimited access to black coffee enormous amounts of coffee per day. The men used caffeine to try and increase their energy.

Behaviors Anorexia

- Fairly straightforward, they restrict. They likely have a very complex system of “rules” they follow to determine which foods are “safe” and which foods are not. They tend to have a very small variety of foods they will eat, may eat them in the same order, same time of day. “Sameness” is often key.

- Make sure to ask about exercise. The amount of exercise may not be as concerning as the compulsive drive behind it. Look for compensation.

- “If you couldn’t climb a flight of stairs after each meal what would you do?”- “If there were no “safe foods” available what would you do?”

Behaviors Anorexia

- Ask about purging. There is a subtype of anorexia called “anorexia, binge-purge.” These patients may primarily restrict but have episodes of binging and purging. These patients may also purge without a preceding binge.

- Ask about caffeine use: used as a diuretic and energy boost. This can be a remarkable amount.

BehaviorsBulemia

- Purging: It’s not only self induced vomiting! - Alternative forms of purging include excessive exercise (ask about the

compulsive nature), laxatives, diuretics, ipecac, amphetamines, diet pills, thyroid medications. Patients may engage in several of these methods.

- In your type 1 diabetics ask about insulin restriction.- Be aware that some chronic purgers do not need to gag themselves to induce

vomiting and may not have the classic Russell’s Sign.

Behaviors In all eating disorder behaviors you want to try and understand how compulsive the behavior is. Inflexible thinking is a hallmark of eating disorders.

Example: It’s healthy to go for a run in the morning. It’s not healthy to avoid a weekend trip with friends because you can’t run in the morning. Or, you go on the weekend trip but restrict food while on the trip because you can’t run in the morning.

Medical Complications Every body system is affected by malnutrition. In short, the body is shutting down and going into a hibernating state.

Changes in vital signs

- Decreased body temperature (In the Key’s study the men’s body temperature dropped to 96F)

- Bradycardia (Hospitalize if <50bmp)- Hypotension (Hospitalize if Systolic <90)- Orthostasis

Medical ComplicationsMuscle wasting:

- Decreased cardiac size- Weaker intestinal muscles may contribute to constipation - Gastroparesis - Decreased global strength- Weight loss, decreased metabolic rate

Medical ComplicationsFrom purging:

- Chronic reflux: voice changes- Gastric rupture- Esophageal rupture

Medical ComplicationsPsychiatric

- Always assess for depression and suicidal ideations. - Eating disorder patients typically die from heart failure, electrolyte imbalances

and suicide. - There is evidence to support use of SSRIs (Prozac) in bulimia to help manage

the urge to binge. - There are no medications approved to treat anorexia. Zyprexa is the only

medication that has any evidence to help patients gain weight but most refuse to take it.

Criteria for Hospitalization according to AAP Anorexia Nervosa

- Weight loss below 75% expected for health- Bradycardia <50bpm daytime or 45bpm nighttime- Systolic BP below 90mmHg- Orthostatic changes in pulse or blood pressure- Body temperature less than 96°F- Cardiac arrhythmias

Bulimia Nervosa

- Electrolyte imbalance (potassium and/or chloride)- Syncope- Hematemesis- Intractable vomiting- Esophageal tears

Multidisciplinary Team- A full multidisciplinary team will involve:

- Therapist, ideally one who specializes in eating disorders- Dietician, imperative they have some training in how to treat eating disorder patients- PCP- Psychiatrist - Consider using the school nurse for weekly weights and vitals if unable to have pts come to clinic

weekly.

“The Secret Language of Eating Disorders”- Julie O'Toole Example: (Said to a child who has been in the hospital for weight restoration, very ill and who now begins to look like there is life in them) “You look wonderful!” Translation: "You look fatter."

Example: “You look more like my child again.” Translation: "I will not be satisfied until you are fat again"

Example: (Said by a grandmother in desperation and deep concern) “I wish you would eat a bit for the sake of your mother, honey.” Translation: "You are ruining your parents’ lives."

Example: (Said by unwitting, inexperienced doctor) “Great job with your food today!”Translation: "You ate like a pig."

Example: (Said by a father to portray sympathy with the child’s dilemma when given dinner) “That is a lot of food.” Translation: “You are being fattened up and if you eat it all you are a pig.”

“The Secret Language of Eating Disorders”- Julie

O'Toole Example: (Said by a parent to a family friend) “I am so proud of her/him. She/he is doing everything the doctors ask without a problem.”Translation: "You are being disloyal to your eating disorder; you give in too easily; you are making it easy for them to fatten you up. You are weak."

Example: (Said by a proud parent to the doctor) “I am proud of how she is cooperating so well with you”.Translation: "She is weak. She doesn’t really have an eating disorder."

Example: (Said by parent in family session) “I never eat breakfast myself.”Translation: "Only fat people eat breakfast."

Example: (said by a parent in family session) “We love our child no matter what size she/he is”Translation: "Even though she/he is fat we love her/him. Because we are her/his parents and we have to."

Eating Disorder Questionnaires Eating Disorder Examination Questionnaire (EDE-Q)

http://cedd.org.au/wordpress/wp-content/uploads/2014/09/Eating-Disorder-Examination-Questionnaire-EDE-Q.pdf

References

Tucker, T. (2006). The Great Starvation Experiment: The Heroic Men Who Starved so That Millions Could Live. New York, NY: Free, Print.

7. Guetzkow, Harold Steere., and Paul Hoover. Bowman. Men and Hunger, a Psychological Manual for Relief Workers. Elgin, IL: Brethren House, 1946. Print.

8. O’Toole, J (2011, July 30). The Secret Language of Eating Disorders. Retrieved from https://www.kartiniclinic.com/blog/post/the-secret-language-of-eating-disorders/

9. Eating Disorder Questionnaire (n.d.) Retrieved from http://cedd.org.au/wordpress/wp-content/uploads/2014/09/Eating-Disorder-Examination-Questionnaire-EDE-Q.pdf